Village Health Care Center

In the surveyor’s words

From the most serious findings on record at Village Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 24, 2026

  On 02/19/26, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision for a resident at high risk for elopement. Resident #1 eloped from the facility on five occasions. On 01/16/26, Resident #1 eloped and, while away from the facility, harmed themselves by intentionally burning the back of their hand with a cigarette lighter which resulted in multiple blisters to the back of their hand. On 02/08/26, Resident #1 eloped and was found by the local authorities at a residence the facility identified as a known drug house. For each elopement, the facility intervention was to initiate every 15-minute visual checks and no interventions were added to Resident #1's care plan. […]

• No harm, potential for more than minimal, widespreadF909Aug 28, 2025

  Based on observation, record review, and interview, the facility failed to ensure routine safety inspections of resident bed frames and bed rails were conducted for 3 (#3, 4, and #28) of 4 sampled residents reviewed for accident hazards.Maintenance #1 identified 48 residents who used facility-maintained bedframes.Findings:On 08/26/25 at 10:13 a.m., Res #4 was observed laying in their bed. The bed was observed to have a 1/8 sized side rail attached to the bed frame.On 08/26/25 at 11:02 a.m., Res #28 was observed laying in their bed. The bed was observed to have a 1/8 sized side rail attached to the bed frame.On 08/27/25 at 12:30 p.m., Res #3 was observed laying in their bed. […]

• No harm, potential for more than minimal, patternF605Aug 28, 2025

  Based on record review and interview, the facility failed to ensure residents were not prescribed antipsychotic medication for the medical diagnosis of dementia for 2 (#40 and #45) of 5 sampled residents reviewed for unnecessary medications.The ADON stated seven residents in the facility were prescribed antipsychotic medications. Findings:A facility policy titled Antipsychotic Medication Use, dated July 2022, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.1.A medication order for Res #40, dated 06/19/25, showed the resident was to be administered Seroquel (a medication approved to treat psychotic disorders) 25 mg, 2 tablets to equal 50 mg by mouth every day and evening for vascular… […]

• No harm, potential for more than minimal, patternF628Aug 28, 2025

  Based on record review and interview, the facility failed to provide a written notice of transfer for residents who transferred to a hospital for 3 (#28, 40, and #47) of 3 sampled residents reviewed for hospitalizations. The ADON stated 54 residents had been transferred to a hospital between 02/27/25 and 08/27/25.Findings:An undated facility policy titled Transfer or Discharge, Emergency, did not show the requirement to send a written notice of transfer to the resident and resident representative prior to transfer.1.A progress note for Res #40, dated 07/21/25 at 10:45 p.m., showed the resident was transferred to a hospital on that date for tremors and unresponsiveness.On 08/27/25 at 11:44 a.m., the ADON was asked about the paperwork that was sent with Res #40 when they were sent to a… […]

• No harm, potential for more than minimal, patternF842Aug 28, 2025

  Based on record review and interview, the facility failed to ensure routine catheter care was documented in the clinical record for 1 (#5) of 1 sampled resident reviewed for catheter care.The ADON reported 5 residents had an indwelling urinary catheter.Findings:An undated Catheter Care, Urinary policy, read in part, The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care.A quarterly assessment, dated 07/24/25, showed Res #5 had a BIMS (a test for cognition) score of 12, which was indicative of moderate cognitive impairment. […]